Objectives
To assess the relationship between stage of pelvic organ prolapse and self-expressed patient goals at initial urogynecologic evaluation.
Study Design
From February to December of 2010, women presenting for evaluation of pelvic floor disorders were asked to identify up to 5 goals for treatment. Charts were reviewed for demographics. Patients were grouped according to stage of prolapse and goals were grouped into 9 categories.
Results
Two hundred twenty-six women completed the questionnaire. Relief of urinary symptoms were the most commonly stated goal regardless of prolapse stage, pelvic organ prolapse quantitative-0 (59%), pelvic organ prolapse quantitative-I (78%), pelvic organ prolapse quantitative-II (55%), and pelvic organ prolapse quantitative-III (58%). Lifestyle, daily activity, and sexual function goals were the second, third, and fourth most common goals in all stages, respectively.
Conclusion
Resolution of urinary symptoms, ability to perform daily activities, and sexual function goals are at least as important as resolution of prolapse symptoms and may be the reason for seeking care.
Pelvic floor disorders are significant causes of symptoms that decrease womens’ quality of life and interfere with daily activity. Women seek care to address these symptoms and improve their quality of life. Treatment success is usually defined from the surgeon’s perspective; surgical tradition teaches the gynecologic surgeon to restore anatomy, and assumes that normal function will be restored. It is becoming apparent that patient-centric outcome measures are increasingly being used to assess patient satisfaction. Patient-identified or patient-centered goals have been described as the “fourth dimension” of pelvic floor disorder assessment, after physical findings, symptoms, and quality of life. Pelvic floor disorders (PFD) treatment goal attainment is known to be associated with improved condition-specific quality of life and patient satisfaction.
Patient-selected goals can be used in assessing the efficacy of treatments in which objective measurements may not be as important as subjective improvement. For example, studies have shown that in disorders that affect quality of life, the patient’s perception of goal achievement impacts her overall satisfaction more than anatomic cure. Furthermore, objective cure of stress incontinence and pelvic organ prolapse were not shown to be the primary predictors of patient satisfaction after surgery. Rather, the degree to which they achieved their stated goals for surgical treatment were much more predictive of perceived success.
The majority of studies evaluate the achievement of patient-centered goals in women undergoing surgical or nonsurgical treatment of their pelvic floor disorders. Patient goals can range from specific symptom relief to general lifestyle improvement. However, the association between patient goals in seeking care and stage of pelvic organ prolapse has not been previously studied. We searched Medline from 1952 to May 2011 using the key terms “patient,” “goal,” “prolapse,” and “pelvic floor,” and identified no studies that examined this relationship. Our aim was to assess self-reported goals at initial urogynecologic presentation and to determine whether patients’ goals differed by stage of prolapse. We believe that a better understanding of unmet patient expectations may identify opportunities for improving delivery of care.
Materials and Methods
After institutional review board approval, all new patients referred to our center for evaluation and treatment of pelvic floor dysfunction from February to December of 2010 were offered enrollment. Our setting is a regional referral practice in a community teaching hospital. Patients were excluded if they were under 18 years old, not proficient with reading English, or had any impairment precluding comprehension of the questionnaire. Patients who agreed to participate were asked by ancillary staff to fill out the questionnaire before being seen by a practitioner. The questionnaire asked patients about general demographic information, exercise habits, and sexual activity. Patients were also asked to self-rate the severity of their pelvic floor condition. Women were then asked to list up to 5 treatment goals in an open-ended fashion, and to grade the importance of achieving each goal (from 1 [very important], 2 [important], 3 [somewhat important] and 4 [not very important]). Each patient underwent a complete history and physical examination, including measurement of pelvic organ prolapse with the pelvic organ prolapse quantitative (POPQ) system per our usual clinical protocol. In addition, all women who are new to our practice are requested to complete the short form of the Pelvic Floor Distress Inventory (PFDI-20) and if sexually active, the short form of the Pelvic organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). Summary scores for the PFDI and subscale scores were calculated according to published algorithms. Prolapse stage, clinical diagnoses, PFDI-20, and PISQ-12 scores were obtained from chart abstraction. Clinical symptoms were obtained from history and not from items on the standardized questionnaires.
Patients were grouped according to stage of prolapse by the pelvic organ quantification examination that was performed at their initial evaluation. Goals were classified into categories of symptom relief (urinary, anorectal, pain, or prolapse), daily activity, sexual function, general health, information seeking, treatment planning, and anxiety resolution. The goal categories were created after reviewing all of the goals submitted. The development and assignment of categories were performed by physician reviewers (the first and second author), with assistance from the principal investigator.
There was no a priori sample size or power calculation. We used a sample size of convenience and aimed to obtain 200 surveys given our timetable and resources. All statistical tests were performed using SAS 9.2 (SAS institute Inc, Cary, NC). All tests were 2 sided, and P values < .05 were considered statistically significant. Data are presented as mean and standard deviation (SD), median and interquartile range, or proportion. Comparisons between prolapse stage groups were made using a χ 2 or Fisher exact test for categorical variables and parametric or nonparametric tests for continuous variables, as appropriate. Median values and interquartile ranges (IQR) were reported for nonnormal distributions.
Results
During the study period, there were 963 eligible patients. Patients were enrolled in the study when the research fellow was present in clinic. Therefore, 481 patients were offered enrollment. Of those confirmed eligible, 226 women (47%) completed the questionnaire and had a total number of 631 goals. The percentage of patients in the POPQ stages 0, 1, 2, and 3 groups were 28% (n = 63), 30% (n = 67), 26% (n = 60), and 16% (n = 36), respectively. No patients had stage 4 prolapse. The majority (91%) of patients were white. The mean patient age increased with prolapse stage; women with stage 3 prolapse were on average 20 years older than those with POPQ-0 (62.7 ± 10.7 vs 43.0 ± 13.1; P < .001). The majority of patients rated all of their goals as very important, so this was not formally analyzed.
In the patients with POPQ-0, 84% described themselves as sexually active and 81% noted having had vaginal intercourse in the last year. Rates of sexual activity decreased slightly with increasing prolapse stages. In patients with POPQ-I, POPQ-II, and POPQ-III, the rates of vaginal intercourse in the last year were 64%, 63%, and 61%, respectively. This was similar to the self-described sexually active status rates in each group (POPQ-1: 67%, POPQ-II: 64%, and POPQ-III: 64%, respectively), but these differences were were not statistically significant ( P < .05).
In patients with no prolapse (POPQ-0), 87% described themselves as being in good, very good, or excellent health, whereas only 13% described themselves as being in fair or poor health. Interestingly, for patients with advanced prolapse (POPQ-III), all patients described themselves as being in good, very good, or excellent health, despite average older age and higher severity of pelvic floor condition. Thirty-eight percent of patients with stage 3 prolapse stated their pelvic floor condition was severe, compared with 19% in the stage 0 group ( P < .23). The frequency of patients reporting severe pelvic floor dysfunction was similar in patients with stage 2 and 3 prolapse (22% and 23%, respectively). Table 1 highlights the demographics and self-described characteristics between patient groups.
| Characteristic | POPQ 0 n = 63 n (%) | POPQ 1 n = 67 n (%) | POPQ 2 n = 60 n (%) | POPQ 3 n = 36 n (%) | P value |
|---|---|---|---|---|---|
| Age, y, mean ± SD | 43.0 ± 13.1 | 52.0 ± 13.5 | 55.5 ± 12.1 | 62.7 ± 10.7 | < .001 |
| Marital status | < .001 | ||||
| Single | 23 (37.1) | 8 (11.9) | 2 (3.3) | 3 (8.3) | |
| Married | 32 (51.6) | 47 (70.2) | 44 (73.3) | 24 (66.7) | |
| Divorced | 5 (8.1) | 5 (7.5) | 6 (10.0) | 5 (13.9) | |
| Separated | 2 (3.2) | 4 (6.0) | 2 (3.3) | 0 (0.0) | |
| Widowed | 0 (0.0) | 3 (4.5) | 6 (10.0) | 4 (11.1) | |
| Vaginal parity—median (IQR) | 0.0 (0.0–1.0) | 2.0 (1.0–3.0) | 2.0 (2.0–3.0) | 2.0 (1.5–2.5) | < .001 |
| Race/Ethnicity | .06 | ||||
| White/Caucasian | 54 (88.5) | 59 (89.4) | 56 (93.3) | 34 (97.1) | |
| Black/African American | 1 (1.6) | 1 (1.5) | 2 (3.3) | 0 (0.0) | |
| Asian/Pacific Islander | 1 (1.6) | 5 (7.6) | 0 (0.0) | 0 (0.0) | |
| Hispanic/Latino | 5 (8.2) | 1 (1.5) | 1 (1.7) | 0 (0.0) | |
| Other | 0 (0.0) | 0 (0.0) | 1 (1.7) | 1 (2.9) | |
| Vaginal intercourse in past year | .08 | ||||
| Yes | 51 (81.0) | 43 (64.2) | 37 (62.7) | 22 (61.1) | |
| No | 12 (19.1) | 24 (35.8) | 22 (37.3) | 14 (38.9) | |
| Self-described as sexually active | 53 (84.1) | 45 (67.2) | 38 (64.4) | 23 (63.9) | .05 |
| Exercise | .74 | ||||
| Yes | 46 (74.2) | 51 (77.3) | 44 (74.6) | 30 (83.3) | |
| No | 16 (25.8) | 15 (22.7) | 15 (25.4) | 6 (16.7) | |
| Median number goals a | 3.0 (2.0–4.0) | 2.0 (1.0–4.0 | 3.0 (1.0–4.5) | 3.5 (2.0–5.0) | .009 |
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
